Region E (the best region) Meeting 2017 Welcome to State and WA Rural Health Access Preservation

Pat Justis, Director, WA State Office of Rural Health Objectives

• Introduce our WA Rural Health team • Provide a glimpse of Washington State, never to be confused with the Other WA • Demonstrate why WA is amazing and why‐other than you‐no one should move here. • Discuss some lessons learned from WA Rural Health Access Preservation/SIM grant/Flex innovation WA DOH Rural Health Team

• Office of Community Health Systems Director‐ Steve Bowman • Rural Health Executive Director‐Pat Justis • SORH Program Manager‐Bonnie Burlingham • Rural Hospital Program Manager‐Lindy Vincent • Rural Hospital QI Coordinator‐Danielle Messier • Workforce Advisor‐Jawana Akuffo • J‐1 Visa Waiver Program/Workforce‐Renee Fullerton Our team continued

• Rural Health Epidemiologist‐Asnake Hailu • Office of Primary Care Manager‐Sam Watson‐ Alvan • Health Analyst ( HPSA) Laura Olexa • Health Analyst ( HPSA and Adverse Events)‐Randy Saylor Ten reasons we loooove WA in random order 1. We have the best river names

Humptulips, Duckabush, Hamma Hamma, Big Quilicene Dosewallips, Dungeness, Duwamish, Nooksack, Chilliwack, Pilchuck, Skookumchuck, Klickitat, Snoqualmie, Nisqually, Snohomish, Stillaguamish, Skykomish, Skokomish, Samish, Sammamish, Snahapish, Washougal, Wynoochee, Queets, Snake, and Bumping River 2. We have ‘pronounce the name’ tests

Can you say? • Puyallup • Sequim • Spokane • Yakima • Methow Correct and Incorrect • Puyallup • Pew‐all‐up not pu‐yall‐ up • Sequim • Squim, not See‐quim

• Spokane • Spo‐can, not Spo‐Kane

• Yakima • Yak‐i‐mah not Yah‐key‐ muh • • Methow Met‐how, not Meth‐ ow 3. We have fifty adjectives for rain (an excerpt)

• Partially cloudy and • Blowing sideways moist • Pounding • Barely misting • Drowning • Wet fog • Pelting • Sprinkling • Penetrating • Tinkling • Blasting • Drizzling • Bouncing • Little drops • Gushing 4. We are known for and REI…fashion

The healthy look: • Birkenstocks with or without socks • Gortex raincoats • Polar fleece • Flannel • Lug sole hiking boots 5. Famous musicians live and make/made music here

• Heart • Bikini Kill • Nirvana • The Melvins • Pearl Jam • Macklemore • • Robert Cray • • • Green River • Quincy Jones • Band of Horses • The Posies • Kenny G • Paul Revere and the • Merilee Rush Raiders • Alice in Chains • Modest Mouse RIP

• Jimi Hendrix • Mia Zapata • Kurt Cobain • Chris Cornell Not to be forgotten, also home to:

• Gas Huffers • Poor Old Lu • Bundle of Hiss • Mommy Long Legs • Minus the Bear • • Best Kissers in the • A Fine Frenzy World • Murder City Devils • Botch • Pedro the Lion • Critters Buggin • Skin Yard 6. We can smell rain

Our noses have a highly developed capacity to smell Pacific storm clouds from miles away. 7. Our state has nearly every terrain and ecosystem • Alpine mountains • Volcanos • Coastal valleys • High desert • Great Plains Steppe • Temperate forest • River gorge • Wetlands • Rainforest

8. We are a geological wonder

“ Like nowhere else on Earth, eastern Washington is a dynamic land of contrasts shaped by colossal, cataclysmic floods, first of hot, searing basaltic lava, followed millions of years later by frigid, massive glacial outbursts.”

Bjornstad, Kiver 9. A timber baron named Sam Hill built a castle for his Romanian Princess and it is filled with Rodin sculptures He also constructed a Stonehenge replica with astronomical accuracy 10. We are home to Bigfoot, the Sasquatch Seven reasons you should tell other people not to move here 1. We have fifty words for rain

• Barely Misting • Blowing sideways • Wet fog • Pounding • Sprinkling • Sluicing • Tinkling • Drowning • Drizzling • Pelting • Bouncing • Penetrating • Gushing • Blasting 2. We kill people with our mud, not a joke • People die when they think they can walk across the bay mud at low tide. • We also have deadly mud slides, a serious and tragic matter. (Oso mudslide March 22, 2014, at 10:37 a.m. , 43 died) 3. Our slugs devour everything

https://mcphee.com/products/ banana‐slug‐mask BANANA SLUG MASK •Latex slug mask •Posable feelers •Great for irritating gardeners •Fits most adult heads $24.95 4. We live near active volcanos

Mt. St. Helen’s Eruption May 18, 1980

Declared the “most disastrous volcanic eruption in history.” 5. “An earthquake will destroy a sizable portion of the coastal Northwest. The question is when.”

“If, on that occasion, only the southern part of the Cascadia subduction zone gives way—the magnitude of the resulting quake will be somewhere between 8.0 and 8.6. That’s the big one. If the entire zone gives way at once, an event that seismologists call a full‐margin rupture, the magnitude will be somewhere between 8.7 and 9.2. That’s the very big one.” Schulz, Kathryn. The New Yorker, July 20, 2015 Accessed June 20, 2017 “Perhaps I’ve said too much.” 6. There is a reason they call them Killer Whales Just kidding: Orca, Blackfish

• Killer whales are the largest member of the dolphin family and there is no recorded human attack in the wild. • There have been attacks and human deaths in captivity and “experts are divided as to whether the injuries and death were accidental or deliberate attempts to cause harm.” • They can however eat a moose or Great White Shark. • Only in Argentina do they swim on to the beach after prey. Our Orcas eat salmon. 7. Big foot Lessons learned from Washington Rural Health Access Preservation (WRHAP), and State Innovation Model (SIM grant) aka Healthier Washington via Flex innovation Numbers

• 39 Critical Access Hospitals, 6 Rural PPS • About 120 Rural Health Clinics, approx. 2/3 provider based • 29 federally recognized Indian tribes • Over 100+ free clinics (urban medically underserved and rural) • 28 organizations with 250 sites FQHCs • Home health? Working on it…. • X rural EMS agencies? (fresh count underway) The capsule sized background

• New Blue H report released 2014, new facility type highest priority • Formed WA Rural Health Access Preservation (WRHAP), SORH/Flex and WA State Hospital Association (WSHA) • Summer 2015, linked to Healthier WA (SIM Grant) “Payment Model 2” • Added Health Care Authority (HCA) and Department of Social and Health Services WHRAP CAHS

• 13 CAHs most at risk of 39, about a third WA CAHs doing well, a third doing okay, and this third at risk for closure, varying levels of imminence. • Remote and/or serving smallest population base, typically under 1200 residents, FMT reports show trouble, mean avg daily inpt census of 0.5 to 1.5 patients per day • CEOs with willingness, some forward vision Red ink • All but 1 of the 13 WRHAP CAHS is in red ink in nearly every service line. • Flex Monitoring Team reports makes them look better than they are… The first year

• Review of all national model demonstrations • Assessment of state law and rule and Medicare Conditions of participation • Give up inpatient in defined essential services • Dove into cost data detail • Envisioning service delivery changes • Seeking TA for calculating a value based payment system with incentives and with any luck, a transition fund. Healthier WA Payment Model 2

CAHs‐WRHAP Rural Health Clinics • Working with Harold and FQHCs Miller from the • Working with a Center for Healthcare different consulting Quality and Payment group, called Reform Alternative Payment Method 4 (APM4) Overlapping goals

Maintain access

Demonstrate Transform delivery Medicaid payment model system The evolving model

– Test by service line: ED, primary care, LTC first, phase ‐in value payment complexity ED version 1. Define minimum budget: Payers pay for capacity fixed cost; calculated by DOH based on minimum staffing to meet regs and other fixed costs. Pay for percentage of covered lives in total payer mix‐annual per member/resident $. PLUS 2. Per visit payments‐ amount lower for pts who have a payer who contributes and higher for per visit only Adjustments

1. 4 MBQIP measures for quality used for quality adjustments 2. Adjustments based on utilization, incentivizing less ED use

• Per visit adjustments for non‐residents receiving care at CAH, • Adjust for PHD members who go outside district for care The Health Care Authority: Alternate Concept • Pennsylvania envy, Maryland… • Global payment for Inpt, ED, outpatient services (not RHC) and swing, both skilled and LTC. • Medicaid standard measure set* • Budget neutral‐ “increased flexibility.” • Now mandated by state law to demonstrate • Funds for up front care coordination passed in budget provisos in late June

*52 measures in set, 2 align with MBQIP Lessons; O’ So Many

• Swing beds, aging in place and the will of the community: • Challenges to address community‐based alternatives such as assisted living, adult family homes, day health, PACE In real health systems it is all connected

• Inpatient is interwoven throughout allocated costs and revenue streams, staffing the primary cost driver ‐spread across many service lines. • Fiscal models suggest backing out inpatient makes more red ink; CAH if essentially envisioned as the current system. • What if systems were defined for prevention, chronic condition care and a bit of acute? Alternative payments and new care models have to move together

• Cross incentives are • Those who trouble, when FFS understand payment contracts count CPT systems deeply are codes other patient proportionately less touches are not likely to understand captured transformation of • Early adopters face care delivery and risk and “$$$ vice versa. punishment.” How many payers will play?

• Go multi‐payer from the gate • Do not assume payer mix labeling and calculating is apples to apples • Medicare dominant? • Percentage of Medicaid? (moving target…) • Commercial payers? Which ones?

• What happens to uncompensated or undercompensated care cost shifting in the new paradigms? Size STILL matters

• Models for larger CAHs and Rural Hospitals may not work for a subset of small, remote hospitals • What about payment for capacity, aka fixed costs? • Can you broaden to total cost of care without an ACO? • Are regionalization and networks the only path out of the wilderness? Summing it up

• WA is fabulous • You may move here but please discourage others • System transformation is not for sissies but it is exciting and demanding • We are so glad you are here…and Bigfoot is also pleased. Thank You

Pat Justis, MA Executive Director, Washington State Office of Rural Health [email protected] Office 360‐236‐2805 Mobile 360‐338‐2875